Reduction mammaplasty is 1 of the commonly demanded and performed operations in plastic surgery and has a high impact on the female patient’s life.
There are many different approaches and techniques for reduction mammaplasty, each representing advantages and drawbacks. The challenging points are the ability to resect breast tissue adequately, symmetrically with preservation of NAC viability, sensibility, and function, while achieving a good sustained aesthetic result. Thus, it is continually evolving with new methods and modifications of these techniques.
Different pedicle techniques have been designed and named according to the site as superior,1 inferior,2 medial,3 lateral,4 central, or combinations of them.5 The decision which of them is suitable based upon the degree of macromastia, breast ptosis and preference or expertise of the surgeon.
McKissock’s6 technique represents a well-vascularized dermo-glandular bipedicle for safe nipple-areola transposition in huge breast reduction, but it has been criticized as resulting in a flat breast with inadequate projection after long-term follow-up.7,8
Multiple modifications to the technique were done to prevent the major drawbacks of such a technique by beveling of the bipedicle and an S-shaped folding of the upper pole of the pedicle during nipple-areolar complex (NAC) transposition. Lastly, dermal suspension to the lower pole of the pedicle was added for prevention of the secondary ptosis of the reduced breasts on the long term.9
Thus, the rationale intended for the current study was to explore the efficiency and safety of bipedicled McKissock’s technique with 3 new added modifications as a reliable procedure for reduction mammaplasty.
PATIENTS AND METHODS
This study was conducted at the Royal Hospital, Cairo, Egypt, during the period from January 2015 to October 2016 with 12-month follow-up period. The goal of this study was explained in the Arabic language to all subjects before their enrollment in the study, and an informed consent form was signed by and obtained from all of them.
We included 25 female patients, between 18 and 50 years, who were willing to undergo reduction mammaplasty. Exclusion criteria were American Society of Anesthesia score 3 or 4 (high risk for anesthesia), patients with organ failure, diabetes mellitus, collagen vascular diseases, and patients with bleeding tendencies.
Preoperative and Postoperative Patient Assessment
All patients were evaluated by detailed history, careful physical examination, and photographed pre- and postoperatively using Nikon d3200 DSLR Camera, 18–55 mm lens. Photography views were standard anteroposterior, midlateral, and lateral views. Smoking was stopped at least 3 weeks before the procedure.
History included age of the patient, history of cardiac problems, liver disease, renal disease, or a recent drug intake and family history of breast disease. A detailed examination was done to assess for the current breast size, the degree of ptosis, and the status of the breast parenchyma.
We explained to the patients about the incisions, the scars, and discussed the idea of the operation, to know their expectations.
Patients were assessed preoperatively, in the immediate postoperative period and at 3, 6, 9, and 12-month postoperative follow-up. Photographs were taken at each visit.
Blood samples were taken from patients as a routine preoperative preparation for complete blood picture, coagulation profile, liver and kidney functions, and random blood sugar.
Description of the New Modifications for the McKissock’s Technique
Three modifications were added to the bipedicled McKissock’s technique (modified vertical bipedicle technique). First, it included surgical undermining and thinning of the bipedicle for volume reduction and contour enhancement, which allows easier setting of the new NAC. The bipedicle was thinned up to 1.5 cm of thickness, basically between 1.5 and 2 cm (see video, Supplemental Digital Content 1, which displays the new modification for McKissock’s technique. This video is available in “Related Videos” section of the PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A778). The flap is 1.5–2 cm for the safety of blood supply because less than 1.5 cm can compromise the subdermal plexus, and if more than 2 cm represents overload on subdermal plexus by unnecessary fat layers and increases the overall volume of the residual tissues. Bipedicle flap length is maximum 4 times flap width to secure the ratio of 2:1 of both superior and inferior flaps.
The second modification was a dermal suspension of the lower pole for parenchymal support and longer breast shape stability. The third change was an S-shaped folding of the upper pole of the pedicle during NAC transposition to prevent their sagging and inversion.
Preoperative markings of all the patients were done in a standing position. First, a single midline vertical line was drawn from the suprasternal notch to the xiphoid process. Then, breast meridian line was drawn on each side, from the clavicle, 6.5–7.5 cm from the suprasternal notch, down to the NAC at 12 o’clock, and crossing the inframammary crease 10–12 cm from the midline, depending on the size of the rib cage or thorax. After that, the new NAC position was marked between 19 and 21 cm, and a classic Wise pattern10 is drawn with vertical lines of 6–8 cm. Then, the inframammary fold was drawn in the upright; then, in the supine position, slightly above the actual one. Finally, the bipedicle was easily marked before the operation (Fig. 1).
Operations in all patients were done consecutively by the same surgeon under general endotracheal anesthesia, with the patients lying supine with abducted arms at 90 degrees. The surgical field is then sterilized and thoroughly draped. Prophylactic third-generation Cephalosporin antibiotic was given in a dose of 1 g IV before the incision and the infiltration of both breasts by lidocaine 2%, epinephrine 1:200 and normal saline solution 0.9%.
Using an areolatome, the size of the new areola and nipple was marked by an indentation of a 4.2 cm diameter. Besides, intradermal injection of the dermoglandular pedicle, and the intended dermal flaps were done for hydro-dissection and facilitation of the deepithelialization process. After that, incisions and dissection of the previously marked, Wise10 pattern was performed, reaching the breast septum, with preservation of the superior and inferior pedicles (Figs. 2, 3).
As a modification to the original McKissock technique, we performed surgical undermining and beveling of the central part of the breast to reduce bulkiness and make it easier for breast tissue molding. A minimum of 1.5 cm thickness of the dermoglandular flap remained in the subareolar part. For the adjustment of projection and NAC transposition, the upper pole of the bipedicle was folded in an S-shaped form and then sutured at 12 o’clock. The measurement of the upper pole ranged 14–16 cm to nipple and the inferior pole also 14–16 cm to nipple. The same procedure was done on both breasts.
After finishing the resection, leaving lateral dermal flaps of 2 cm width and the NAC transposition, the patient’s torso is elevated and positioned at 45 degrees. As a second modification of the technique, the lateral dermal flaps on either side of the dermoglandular pedicle were transposed and suspended in an internal brassiere form to the pectoral fascia without tension using 2-0 nonabsorbable polypropylene monofilament sutures. The base width of the bipedicle was kept between 8 and 10 cm. The aisles of dermal flaps were the same dimensions in all cases.
The lateral pillars were closed in subdermal and subcuticular layers to form the vertical limb of the inverted T wound. Suction drains were inserted bilaterally; then, the medial and lateral aspects of the inframammary incision were closed and sutured in layers, reaching the T-junction using simple inverted 2-0 and 3-0 absorbable subdermal sutures, and skin was closed with 3-0 subcuticular nonabsorbable polypropylene monofilament sutures. Adhesive sterile pads were used to cover the wounds, and the patient wore a special elastic supporting brassiere for 6 weeks.
The primary outcome measure was to assess the aesthetic result of the modified McKissock’s technique (the bipedicled McKissock’s technique with 3 newly added modifications).
The assessment was done by the objective measurement of the distance between the mid-clavicular point (MCP) and 12 o’clock point of the NAC (12’NAC), in cm, pre- and postoperative at 9 months.
The secondary outcome measures were the measurement of the nipple to inframammary crease (IMC) before the operation and after the follow-up to assess the stability of the results over time, also, to quantify the short-term and long-term complications, as well as, to assess patients’ satisfaction with the results. Patients’ satisfaction was to be measured by using a satisfaction scale, where, 3 is very satisfied (the results matched all the patient’s desires), 2 is satisfied (not all the expectations were met, but still satisfied and do not request reoperation or secondary procedure), and one is unsatisfied.
All statistical tests were done using a significance level of 95%. A value of P < 0.05 was considered statistically significant. SPSS software (Statistical Package for the Social Sciences, version 20.0, SSPS Inc, Chicago, Ill.) was used for the statistical analyses. Data were presented as (mean ± SD) or median (range) for continuous variables and as a frequency and percentage for categorical variables. Comparisons were made using the paired t test for continuous variables.
All 25 patients have had excessively large breasts with different degrees of ptosis. The age of the cases ranged between 22 and 49 years (mean age, 36.2 ± 7.3). The mean body mass index was 30.5 ± 4.3 kg/m2 with a minimum of 24 and a maximum of 38.
The average time of operation was 4 hours. The resected tissue was 630–980 g.
The Postoperative Assessment: Patients’ Satisfaction
Patients were asked about their overall satisfaction, particularly, satisfaction with shape, scar length, and nipple sensation after the operation. The patients were very satisfied in most of the cases (20 cases), satisfied in 3 cases, and 2 cases were unsatisfied as they wanted slightly smaller breasts, as shown in Figure 4.
The Postoperative Assessment
The optimal aesthetic appearance of the breasts was achieved at 6–9 months postoperatively. The better NAC projection was still maintained after 12-month follow-up in the form of better less hyperemic scars and softer breast glandular tissue with enhanced contour caused by natural draping with gravity (Figs. 5 & 6).
The maintenance of improvement was measured by the distance between the MCP and 12 o’clock point of the NAC (12’NAC) (Table 3). It varied between 28 and 43 cm preoperatively (mean ± SD, 34.12 ± 4.19 cm), and between 19 and 22 cm postoperatively (mean ± SD, 20.70 ± 1.03 cm; P value < 0.001; Table 1). The average percentage reduction in MCP-NAC distance was 38.7% ± 6.2% with a minimum reduction of 27.6% and a maximum 48.8%.
Moreover, the nipple to IMC distance varied between 16 and 20 cm preoperatively (mean ± SD, 16.08 ± 1.66 cm), and between 8 and 10 cm postoperatively (mean ± SD, 8.04 ± 0.79 cm; P value < 0.001; Table 1).
No complications detected in 18 cases (72%), superficial wound dehiscence at the T-junction in 3 (12%), which were treated by repeated dressing with topical ointments and creams and seroma in 1 (4%), which completely resolved without further complications, as shown in Table 2. Two cases (8%) demanded smaller breasts, and 1 case (4%) needed surgical revision for widened scars after 11 months. The major drawbacks were NAC sensitivity alteration and the inability to lactate.
Patients consented for the inability to lactate and the sensory changes they might experience postoperatively, and their main concern was basically on the appearance. No further sensory tests were done.
The most important goal of reduction mammaplasty is achieving a stable shape with a good projection of the breasts while minimizing the complications and ensuring a good blood supply to the nipple-areola complex.
Many reduction mammaplasty techniques have been described before, as the single pedicle techniques, the superior pedicle by Weiner,1 the inferior pedicle described by Robbins,2 the medial pedicle by Nahabedian et al.3 and central by Gasperoni et al.11 and are more commonly used nowadays. These techniques can produce good immediate postoperative results; however, they cannot be kept for a long time.12–14 The lateral pedicle described by Skoog4 is less likely used due to the bulky lateral fullness it produces. The horizontal bipedicle technique has been described by Strombeck5 but was also avoided, due to the same aesthetic reasons. The vertical bipedicle described by McKissock6 has the advantages of increased vascular safety to prevent the complication of nipple-areola complex necrosis, while at the same time achieving a fine aesthetic breast shape.
After the first description of the superior pedicle mammaplasty Arie (1957), the technique had been subjected to some refinements by Ivo Pitanguy in 1967.15,16 In 1973, Weiner brought it to the United States describing it for reductions and mastopexy.17 Furthermore, Orlando and Guthrie18 demonstrated the superomedial pedicle technique, which varied only in the more medially directed superior pedicle.19 Moreover, Arufe et al.20 confirmed adequate vascularity of the superior pedicle with preoperative arteriograms on several patients. Durability of results of breast reduction with the superomedial intraparenchymal pillar suturing techniques was demonstrated by Elizabeth Hall-Findlay, which showed good long-term shape that decreased the incidence of bottoming out of the breast over time.21
The primary concern in our research is to add longevity to the new breast shape with an ultra-safe and yet easy technique. The results of the current study showed that the new modifications added to the McKissock’s technique are successful in most of the subjects, with highly satisfactory outcomes. Besides, the assessment of the maintenance of improvement of ptosis was reported by the objective measurements of the distance between MCP and NAC in cm and the nipple to IMC distance. All postoperative complications were resolved completely during the follow-up period.
McKissock’s technique has some disadvantages resulting in broad breasts, long submammary scars, and secondary ptosis or pseudoptosis, caused by the bulky bipedicle. Our modifications include a shorter folded superior pedicle, and a narrow suspended inferior pedicle, which result in shorter submammary incisions. Thinning of the bipedicle increases its malleability in forming a projecting breast shape, while the dermal suspension of McKissock’s vertical bipedicle flap technique is an easy modification that prevents its drawbacks of secondary ptosis.
Hinderer9 described a dermal suspension technique in reduction mammaplasty for suspending the gland in different breast sizes and also in mastopexy. There are additional advantages of dermal suspension of the bipedicle, including the prevention of flat breasts appearance, while also decreasing the tension on the medial and lateral pillars of skin flaps, and thus enhancing the process of healing and minimizing scar formation. Menderes et al.,12 compared the McKissock’s technique with and without dermal suspension and found that the outcome was better with dermal suspension, due to the prevention of bottoming out of the inferior pole and the longest sustained aesthetic shape.
In our study, postoperatively, there was no compromise of the venous return or any signs of nipple-areola complex congestion from the S maneuver.
A critical aspect in reduction mammaplasty is the patient satisfaction of the aesthetic results in the long term. The patients operated on by the modifications of McKissock’s technique with dermal suspension, demonstrated excellent results in breast shape, size, and symmetry. The most fulfilling part was the positive body image, which patients attained after the operation. All patients have a more active social and physical life and are no longer burdened with hypertrophic breasts and the associated signs and symptoms.
Further comparisons to the technique and its modifications are highly recommended for enhanced long-lasting aesthetic breast appearance after reduction mammaplasty.
We can conclude that our modifications for the McKissock’s technique with its maintained aesthetic shape in those patients are a reliable option that can be considered as it is a simple, efficient, and satisfactory method, which can improve the results of reduction mammaplasty operations.
We would like to acknowledge Dr. Emad R. H. Issak (ClinAmygate) for his efforts in statistical analysis and editing of this manuscript.
1. Weiner DL, Dolich BH, Miclat MI Jr.. Reduction mammoplasty utilizing the superior pedicle technique: a six-year retrospective. Aesthetic Plast Surg. 1982;6:7–14.
2. Robbins TH. A reduction mammaplasty with the areola-nipple based on an inferior dermal pedicle. Plast Reconstr Surg. 1977;59:64–67.
3. Nahabedian MY, McGibbon BM, Manson PN. Medial pedicle reduction mammaplasty for severe mammary hypertrophy. Plast Reconstr Surg. 2000;105:896–904.
4. Skoog T. A technique of breast reduction; transposition of the nipple on a cutaneous vascular pedicle. Acta Chir Scand. 1963;126:453–465.
5. Strombeck JO. Mammaplasty: report of a new technique based on the two-pedicle procedure. Br J Plast Surg. 1960;13:79–90.
6. McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast Reconstr Surg. 1972;49:245–252.
7. Ramon Y, Sharony Z, Moscona RA, et al. Evaluation and comparison of aesthetic results and patient satisfaction with bilateral breast reduction using the inferior pedicle and McKissock’s vertical bipedicle dermal flap techniques. Plast Reconstr Surg. 2000;106:289–295; discussion 295.
8. Hirshowitz B, Moscona AR. Modification of the bipedicled vertical dermal flap technique in reduction mammaplasty. Ann Plast Surg. 1982;8:363–369.
9. Hinderer UT. Mammaplasty: the dermal brassière technique. Aesthetic Plast Surg. 1978;2:1–20.
10. Wise RJ. A preliminary report on a method of planning the mammoplasty. Plast Reconstr Surg. 1956;17:367–375.
11. Gasperoni C, Salgarello M, Gasperoni P. A personal technique: mammaplasty with J scar. Ann Plast Surg. 2002;48:124–130.
12. Menderes A, Mola F, Vayvada H, et al. Dermal suspension flaps for McKissock’s vertical bipedicle flap vs. classical McKissock’s technique: comparison of aesthetic results and patient satisfaction. Br J Plast Surg. 2005;58:209–215.
13. Echo A, Guerra G, Yuksel E. The dermal suspension sling: shaping the inferior pedicle during breast reduction. Aesthetic Plast Surg. 2011;35:608–616. doi: 10.1007/s00266-010-9632-5. Epub 2010 Dec 7.
14. Abdelaal MM, Aboelatta YA. Dermo-fascial suspension for better contouring and long lasting results in reduction mammoplasty. Aesthetic Plast Surg. 2015;39:78–83.
15. Arie G. Una nueva tecnica de mastoplastia. Rev Iber Latino Am Cir Plast. 1957;3:28.
16. Pitanguy I. Surgical treatment of breast hypertrophy. Br J Plast Surg. 1967;20:78–85.
17. Weiner DL, Aiache AE, Silver L, et al. A single dermal pedicle for nipple transposition in subcutaneous mastectomy, reduction mammaplasty, or mastopexy. Plast Reconstr Surg. 1973;51:115–120.
18. Orlando JC, Guthrie RH Jr.. The superomedial dermal pedicle for nipple transposition. Br J Plast Surg. 1975;28:42–45.
19. Hugo NE, McClellan RM. Reduction mammaplasty with a single superiorly-based pedicle. Plast Reconstr Surg. 1979;63:230–234.
20. Arufe HN, Erenfryd A, Saubidet M. Mammaplasty with a single, vertical, superiorly-based pedicle to support the nipple-areola. Plast Reconstr Surg. 1977;60:221–227.
21. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the learning curve. Plast Reconstr Surg. 1999;104:748–759; discussion 760–3.